Psilocybin: Perspectives and Possibilities for Nurses with PTSD

Frequent staffing and resource shortages burden nurses with filling these gaps, leading to disproportionate stress in the profession compared to other careers. Alongside this stressful environment, nurses often face difficult decisions regarding patient care due to high nurse-to-patient ratios, extended work hours, increased workloads, and limited resources. Furthermore, they have struggled with shortages of ventilators, hospital beds, and essential supplies throughout the pandemic. Over the past years, many nurses have encountered shortages that forced the rationing of vital life-sustaining resources, requiring staff to make exhausting decisions about which patients receive life-saving treatment and which do not (Liddell et al., 2020). Consequently, due to these demanding conditions and traumatic experiences, nurses are at a greater risk of developing symptoms consistent with post-traumatic stress disorder (Ayotte et al., 2022).

The rate of PTSD among healthcare providers was approximately 18% before the COVID-19 pandemic, which is already higher than the rates reported for the general population (Ayotte et al., 2022). After enduring the COVID-19 pandemic, it is hard to believe that these rates have not dramatically increased. According to a meta-analysis conducted and published in 2022, PTSD symptoms in the healthcare worker population during COVID-19 nearly doubled to 34%. Furthermore, 14% of healthcare workers exhibited severe PTSD symptoms (Andhavarapu et al., 2022).

Recently, emerging psychedelic-assisted therapies have shown notable promise in treating challenging psychiatric conditions, such as anxiety, depression, PTSD, addiction, and end-of-life distress. Psilocybin-assisted therapy has received 'breakthrough therapy' designation from the Food and Drug Administration for treatment-resistant major depressive disorder (MDD) and PTSD (Bird et al., 2021). As more states vote to decriminalize and legalize psilocybin for therapeutic use, it could reduce biases and become a more acceptable treatment option for this specific population. This observation is not unique, as the University of Washington is currently enrolling healthcare workers to study psilocybin-assisted psychotherapy for front-line COVID-19 workers experiencing depression and burnout (Beck, 2021). (AUTHOR: This citation is not in the reference list)

Background

PTSD

The American Psychiatric Association defines PTSD as the occurrence of recurring, intrusive, distressing memories or dreams, along with reactions to internal or external cues that are dissociative or resemble aspects of a traumatic event experienced by an individual (American Psychiatric Association, 2022). The traumatic event may involve a threatened or actual experience of death, sexual assault, or injury that affected the individual, a close friend, or a family member (American Psychiatric Association, 2017). Consequently, individuals coping with this disorder tend to avoid situations that could trigger trauma by provoking controlling thoughts, emotions, or memories. They may also try to steer clear of certain people, specific places, or particular conversations that might serve as reminders of the trauma. Those who suffer from PTSD may experience a range of negative symptoms like those of major depressive disorder (MDD), which include social withdrawal, negative emotional states, and anhedonia. Additionally, positive symptoms such as self-destructive behavior, irritability, hyper-vigilance, sleep disturbances, and decreased concentration may also manifest (American Psychiatric Association, 2022).

PTSD Treatment Modalities

In terms of psychotherapy, SSRIs are not only the first-line treatment; they are the only pharmacological class approved due to their low side effect profile. However, individuals experiencing PTSD also face treatment resistance (Liriano et al., 2019). Given the complex nature of PTSD, current recommendations emphasize trauma-focused psychotherapy as the first-line and preferred treatment for this condition. This form of psychotherapy includes both exposure therapy and a combination of cognitive therapy, formally known as "trauma-focused cognitive behavioral therapy" (TF-CBT) (Elsouri et al., 2022). The primary objective of TF-CBT is to assist those affected by trauma in managing difficult emotions more effectively and to develop tools for reshaping distorted perceptions (Elsouri et al., 2022). Treating PTSD remains challenging, as TF-CBT is not accessible to all patients, and some may prefer medication instead (Elsouri et al., 2022).

Extant literature demonstrates a significant lack of researched treatment options and a strong need for alternatives to assist this vulnerable population. Furthermore, clinicians prescribe atypical antipsychotics like quetiapine and risperidone for symptom-focused management. However, research has previously indicated that risperidone, when compared to a placebo, showed no difference in alleviating typical PTSD symptoms (Liriano et al., 2019). Other options are available beyond atypical antipsychotics, including mood stabilizers, hypnotics, and anxiolytics. Nonetheless, all these options are off-label and have limited trials and efficacy regarding PTSD treatment (Liriano et al., 2019).

Psilocybin

Psilocybin was first studied in the mid-1900s but was banned as a Schedule I drug under the Controlled Substance Act of 1970 (Bird et al., 2021). In 1992, the FDA authorized the revival of psilocybin research. Over the past 30 years, numerous studies have explored the use of psilocybin in various treatment methods, including alcohol dependence, anxiety, tobacco cessation, and depression associated with life-limiting illnesses and the demoralization experienced by long-term AIDS survivors (Penn et al., 2021).

The mechanism of action for psilocin, the active metabolite of psilocybin, involves the agonism of several different 5HT receptors, including 5HT-2A, 5HT-2C, and 5HT-1A receptors (Elsouri et al., 2022). Psilocybin induces its hallucinogenic effects, specifically through the 5HT-2A receptor, and enhances the activities of the amygdala's visual and prefrontal cortex regions. The downregulation of the amygdala in response to fearful stimuli is believed to be related to psilocybin's mood-elevation effects (Elsouri et al., 2022). Although the exact pathophysiology is not fully understood, it is hypothesized that it arises from a dysregulated fear response (Abdallah et al., 2019). It is not uncommon for depressive and negative thoughts to accompany PTSD diagnoses; thus, psilocybin's ability to augment positive mood states may have therapeutic applications for this population (Bird et al., 2021; Elsouri et al., 2022).

The study by Catlow et al., published in 2013, provides evidence that psilocybin administered to animals can stimulate nerve cell regrowth, or neurogenesis, in the hippocampus, the part of the brain responsible for memory and emotion (Catlow et al., 2013). Catlow et al.'s research demonstrated that the mice receiving psilocybin were better able to overcome fear conditioning than the control group given the placebo (Catlow et al., 2013). While further study is needed, this information supports the hypothesis that psilocybin may help patients with PTSD by breaking the cycle of trauma.

Psilocybin Research

Thus far, the results of currently published studies have been remarkably positive. In a randomized, double-blind, crossover trial conducted by Johns Hopkins University, researchers administered low-dose versus high-dose psilocybin to a group of 51 cancer patients facing potentially fatal diagnoses along with symptoms of depression and anxiety (Griffiths et al., 2016). (AUTHOR: This citation is not in the reference list) At the 6-month follow-up, 80% of participants who experienced the high-dose psilocybin reported clinically significant improvements in self/life, mood, relationships, and spirituality, alongside reductions in depressed mood and anxiety (Griffiths et al., 2016). (AUTHOR: This citation is not in the reference list)

The percentage of participants endorsing moderately or greater improved well-being and life satisfaction was astonishingly higher than 80% (Griffiths et al., 2016). (AUTHOR: This citation is not in the reference list) In a 4.5-year follow-up conducted by Agin-Leibes et al., those still alive showed significant improvements, with 71-100% attributing these enhancements to the psilocybin-assisted therapy (Agin-Leibes et al., 2020).

A long-term follow-up analysis article discussing the crossover study of psilocybin-assisted psychotherapy for patients with cancer-related distress, conducted by Stephen Ross at NYU, stated that psilocybin could rapidly reduce depression and anxiety in patients with cancer confronting end-of-life challenges (Simoneaux, 2020). Additionally, the article emphasizes that it requires only one or two doses of psilocybin to produce these positive effects, highlighting the potential for a reduced risk of dosing-related toxicities associated with its administration (Simoneaux, 2020).

An additional study focused on 12 patients experiencing moderate-to-severe, unipolar, treatment-resistant major depression who were given psilocybin in a supportive setting (Carhart-Harris et al., 2016). The findings of this study by Carhart-Harris were as follows: the adverse reactions were all transient and included confusion or thought disorder, nausea, headaches, and anxiety that lasted during the onset of the drug. These transient "adverse reactions" provide preliminary support for the statement that psilocybin is both safe and effective (Carhart-Harris et al., 2016). A subsequent randomized clinical trial of psilocybin-assisted psychotherapy involving 24 participants with major depressive disorder, conducted at the Johns Hopkins Center for Psychedelic and Consciousness Research, demonstrated similar successful antidepressant effects at one- and four-weeks following treatment (Davis et al., 2021; Penn et al., 2021).

In a safety and feasibility study conducted in a major U.S. city, eighteen older long-term AIDS survivor (OLTAS) men who self-identified as experiencing moderate-to-severe demoralization participated in a psilocybin-assisted group therapy clinical trial. In the three-month follow-up, this study revealed a significant reduction in demoralization (Anderson et al., 2020).

Finally, research targeting healthcare workers has begun at the University of Washington. The principal investigator, Anthony Back, MD, has initiated the first clinical trial of psychedelic-assisted psychotherapy for healthcare workers dealing with burnout and depression specifically related to front-line efforts during the COVID-19 pandemic. The study acknowledges the difficulties clinicians on the front lines have encountered in recent years and recognizes that these challenges persist and are far from resolved. Current research on psilocybin-assisted psychotherapy has shown promising results for mental health conditions that correspond with the symptoms healthcare workers report as linked to their front-line roles. The study has received approval from the FDA and the University of Washington IRB, and participant identities are kept confidential. As a society, it is crucial to recognize the psychiatric challenges healthcare workers face and to provide effective treatment options for this population. (AUTHOR—Please cite this information as needed)

Relevant Legislation

On November 3, 2020, Oregon Measure 109, known as the Psilocybin Program Initiative, was approved. This vote empowered the Oregon Health Authority (OHA) to establish a program that permits licensed service providers to administer psilocybin-producing mushrooms and fungi products to individuals aged 21 and older (Oregon Measure 109, 2022). In September 2022, San Francisco decriminalized plant-based psychedelics, including psilocybin, through resolution #220896. In November 2022, Colorado voted to decriminalize psychedelic mushrooms for individuals over 21 and to set up state-regulated "healing centers" where participants can experience therapeutic effects under supervision starting in 2024 (Colorado Proposition 122, 2022).

The Role of Nursing

Despite being acknowledged as the group that could benefit from psilocybin-assisted psychotherapy, the field of psychedelic therapy is expanding, and nursing can play a crucial role in continuing to develop effective and safe methods for psychedelic-assisted therapies. Research has shown that psychedelic-assisted therapies hold significant potential to alleviate suffering and promote growth, healing, and peace in the face of illness, and nurses are well-prepared to contribute (Penn et al., 2021). A 2020 article noted that the role of nurses in psychedelic-assisted therapy is largely absent, underexplored, and ill-defined (Denis-Lalonde & Estefan, 2020). There is a tremendous opportunity for the nursing profession to grow as advocates, educators, and leaders within this emerging field.

The knowledge, skills, and values embedded in nursing education and applied to patient care are essential for the effective implementation of psychedelic therapy. Nursing education involves training staff to address physical, emotional, mental, and spiritual needs in various capacities, enabling nurses to be valuable assets during psychedelic-assisted therapies. Therefore, nursing must set aside socio-political biases regarding these mind-altering drugs, as doing so would hinder progress and potentially restrict access to transformative treatments.

Limitations of Psilocybin Use

Despite the positive findings from recent publications, it is important to acknowledge that psilocybin is still classified as a Schedule I substance at the national level. While some states have decriminalized psychedelic fungi, it remains illegal federally. The current legal status is restrictive; thus, for more extensive research to take place, the legality of psilocybin must change. This legal framework presents challenges for FDA approval, limiting the number of available studies and obscuring many people's perceptions of the validity of psychedelic-assisted therapies. Moreover, this article explores the administration of psilocybin, a Schedule I substance, among healthcare workers. There will be an inherent bias in participating in this type of therapy due to psilocybin's illegal status. This legal aspect can hinder further research within this population, postponing results or therapeutic application if psilocybin proves to be as beneficial as research suggests.

Furthermore, of the studies listed above, the oncologic patient study totaled 29 patients (Simoneaux, 2020), the AIDS study had 18 participants (Anderson et al., 2020), and the unipolar depression study totaled 12 individuals (Carhart-Harris et al., 2016). Despite promising results, these are all small sample sizes, and further research is needed in a broader sample size to generalize the efficacy of psilocybin. Most importantly, there is limited information on healthcare workers experiencing PTSD because of their profession, in addition to scholarly articles supporting different treatment options specific to this population.

Final Considerations

Literature indicates that psilocybin-assisted therapies have seen significant success at a micro level. Current studies suggest that psilocybin administration can be largely therapeutic for various mental health disorders. Although infrequently tested, the extant research indicates that psilocybin may affect the same part of the brain that triggers a trauma response, suggesting it could be administered and studied in populations experiencing post-traumatic stress disorder. As psilocybin gains attention in recent media, it is crucial to continue exercising caution and recognizing that, while studies have shown positive results, all published studies have limitations affecting generalizability. It is important to remain optimistic about current and future medical advances, but prudent given that long-term studies on the implications of administering psilocybin (lasting longer than 4.5 years) have yet to be published. Finally, due to the holistic education provided to nurses and their inherent capacity to manage physical, emotional, and spiritual stress, the nursing profession may play a vital role in psilocybin-assisted therapies.

Conclusion

As the COVID-19 pandemic approaches the fifth anniversary of the disease's emergence, healthcare workers are undeniably fatigued, traumatized, depressed, and disheartened. The percentage of PTSD among healthcare workers has nearly doubled since the onset of the pandemic. Treating PTSD remains challenging from a provider's perspective, and FDA-approved treatments are few and far between. Over the last few years, psilocybin has re-emerged as a promising therapy for those experiencing depression and other symptoms consistent with PTSD. Although research on the effects of psilocybin as a treatment for PTSD is limited, there is reassuring evidence that psilocybin administration may be beneficial based on the fungi’s mechanism of action and the suspected pathophysiology of PTSD. The safety and efficacy of psilocybin should be assessed in clinical trials to evaluate its treatment potential for healthcare workers experiencing PTSD.

Authors

Diana Antenucci, BSN, RN, OCN
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Diana Antenucci, BSN, RN, OCN, is an Adult Acute Care Nurse Practitioner MSN candidate at California State University- Los Angeles. She is an RN in the Pediatric ICU / Cardio-Thoracic Care Unit with previous experience working in Adult Oncology Inpatient Units. Diana received her BSN from Villanova University.

Raymund Gantioque, DNP, RNFA, ACNP-BC
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Raymund Gantioque DNP, RNFA, ACNP-BC, is an assistant professor and AGACNP option coordinator at California State University- Los Angeles. He practices as a Nurse Practitioner in the Emergency Department.